The pattern of presentation has altered radically due to the introduction of the serum autoanalyzer. Most PHPT is now discovered incidentally in primary care in minimally symptomatic patients. Traditionally, the presentation of hyperparathyroidism was labelled as “bones, stones, abdominal groans, and psychic moans.” These include bone pain, abdominal pain and cramps, renal stones, and depressed or altered mood.

In the preoperative work-up for all HPT patients, it is important to exclude medically treatable causes of multigland disease by assessing drug history (particularly lithium therapy) and checking for hypovitaminosis D. In addition, a family history of HPT should always be sought, as HPT due to multigland disease is far more likely to be an inherited condition.

Investigations aim to confirm a biochemical diagnosis of PHPT and, in minimally symptomatic disease, to identify evidence of end organ damage so that surgery can be recommended.

All patients presenting with a likely diagnosis of PHPT require a serum calcium and intact PTH assay. In addition a serum vitamin D assay is required, and occasionally vitamin D levels must be replete before the diagnosis can be accurately made.

Although hypercalciuria is no longer an indication to advise parathyroidectomy, a 24 h urine collection for calcium and creatinine should still be obtained to exclude the diagnosis of familial hypercalcemic hypocalciuria (see Chap.​ 31).

Bone density assessment should be considered, particularly in conservatively managed patients to provide a baseline for regular monitoring. A renal ultrasound is performed to determine the presence of renal stones or nephrocalcinosis.

If the need for surgery is established, parathyroid imaging is normally performed (see Chap.​ 32).

This should always be undertaken in a multidisciplinary setting, in close collaboration with an endocrinologist, preferably specializing in bone metabolism, and ideally with a radiologist specializing in head and neck imaging.